Letter from the Chief Inspector of General Practice
This practice is rated as Good overall. (The practice was rated good at our previous inspection 1 October 2014).
The key questions are rated as:
Are services safe? – Requires Improvement
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) - Good
We carried out an announced comprehensive inspection at Sina Health Centre on 5 December 2017. We carried out this inspection as part of our inspection programme.
At this inspection we found:
- The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learnt from them and improved their processes.
- Risks to patients were assessed and well managed, with the exception of those relating to management of safety alerts and or alterations made to patient records in relation to medicines.
- The practice worked closely with other health and social care professionals involved in patient’s care. Regular meetings were held with the community nursing teams and palliative care teams to discuss the care of patients who were frail / vulnerable or who were receiving end of life care.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Patients found the appointment system easy to use and reported that they were usually able to access care when they needed it.
- The practice had reviewed the lower than average GP national survey scores and developed an action plan to address these.
- There was a focus on continuous learning and improvement at all levels within the practice. Staff were encouraged and supported to develop their skills or take forward their ideas, for example the dementia support meeting.
The areas where the provider must make improvements as they are in breach of regulations are:
- Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed. For details, please refer to the requirement notice at the end of this report.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. For details, please refer to the requirement notice at the end of this report.
The areas where the provider should make improvements are:
- Update the chaperone policy to include where staff should stand during the examination.
- Check the information held on locum GPs is current and up to date each time they work at the practice.
- Review staffing to ensure there are sufficient reception / administration staff to meet the needs of the practice.
- Record the serial numbers of prescriptions on receipt at the practice.
- Review and risk assess the range of emergency medicines stocked.
- Implement a system for the review of patient records in relation to changes to medicines, for example, the addition of new medicine or deletion of uncollected prescriptions should be reviewed by the GPs.
- Introduce a structured induction programme for newly appointed members of staff.
- Continue to explore how the patient satisfaction scores in relation to consultations with a GP and accessing appointments from the National Patient Survey can be improved.
- Promote the extended hours appointments to raise patient awareness.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice